Basic Information
| Provider Information | |||||||||
| NPI: | 1366891418 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NALLY | ||||||||
| FirstName: | CRAIG | ||||||||
| MiddleName: | JUDSON | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 FRUIT ST | ||||||||
| Address2: | WHITE 1, | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021142621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177244100 | ||||||||
| FaxNumber: | 6177267415 | ||||||||
| Practice Location | |||||||||
| Address1: | 7 BAILEY ST | ||||||||
| Address2: | |||||||||
| City: | FOXBORO | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020352836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083265767 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2016 | ||||||||
| LastUpdateDate: | 06/09/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 146N00000X | E872236 | MA | N | Emergency Medical Service Providers | Emergency Medical Technician, Basic | 363A00000X | PA5745 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.